将质量要求融入信息系统，以提高检验前质量控制能力

检验医学 ›› 2012, Vol. 27 ›› Issue (10): 844-848.

将质量要求融入信息系统，以提高检验前质量控制能力

田佳乐

同济大学附属同济医院检验科，上海200065

收稿日期:2012-06-13 修回日期:2012-08-02 出版日期:2012-10-30 发布日期:2012-10-12
通讯作者: 万海英，联系电话：021－66111425。
作者简介:田佳乐，男，1984年生，技师，主要从事临床检验工作。
基金资助:
上海申康医院发展中心“临床管理优化项目”（SHDC2011614）

Integration of quality requirements into information systems to improve the quality control ability of pre-analytic process

Department of Clinical Laboratory，Tongji Hospital，Tongji University，Shanghai 200065，China

Received:2012-06-13 Revised:2012-08-02 Online:2012-10-30 Published:2012-10-12

摘要/Abstract

摘要： 目的　为了提高检验分析前环节的质量，利用信息系统对标本流程中的实验室前过程的质量控制要点进行实时提示、查询与监控。方法　改进现有的电子检验申请单模式，实时跟踪、控制标本采集及运送过程中各环节的时间节点，并将标本采集的质量要求及检验项目的相关临床知识要点融入到开单与执行医嘱过程。结果　（1）为临床提供个性化专科或专病种检验申请项目单，如“急诊检验申请项目单”，将可供急诊检验的项目集中于此，全院统一，非此单中所开检验申请一律视为非急诊项目；（2）在医生开单界面，随时通过双击鼠标查看检验项目：名称、标本种类、检测方法、标本采集要求、参考区间、临床意义、干扰因素及检验报告出具时间等内容；（3）护士执行医嘱时，每条检验项目行一栏均显示此项目的抗凝管类别或标本杯的条码前缀、采集量、采集要求及检验报告出具时间等内容；（4）所有人员均可通过“标本状态查询”功能，实时了解标本采集、签发、签收、处理、报告发送、报告打印等系列执行状态信息；（5）护士可通过“标本签收、退回”功能，查询本病区退回标本的原因、时间及操作人员信息。结论　将检验分析前环节的质量控制要求融入信息系统，不仅方便临床医护实时了解检验相关知识的要求，而且完善了实验室对临床医护的培训、沟通体系，受到检验人员及临床医护的高度认可。

关键词: 检验分析前环节, 质量控制, 实验室管理, 实验室信息系统

Abstract: Objective　To utilize the information systems to implement real-time prompts，queries and monitor for the quality control points of pre-analytic process in the specimen procedure in order to improve the quality of pre-analytic process. Methods　　Improving the existing mode of electronic examination application，the time point of various links were tracked real-timely and controlled in the process of specimen collection and transportation，and the quality requirements of specimen collection and relevant clinical knowledge of test items were integrated into the process of examination application and performance. Results　(1) Personalized examination application was afforded for specialist or special disease. For example，"emergency examination application" was available for all of emergency examination items in the whole hospital. Test items from other applications will be considered to be non-emergency tests. (2) The test item would be viewed by double-clicking the mouse on the examination application interface at any time，including name，specimen type，measurement method，the requirements of specimen collection，reference interval，clinical significance，interference factors，test report issuance time and so on. (3) When nurses performed the doctor’s orders，each of test item showed the anticoagulant tube type or bar code prefix，collection volume，acquisition requirements and test report issuance time and so on. (4) All personnel can understand executive status information of specimen collection，signature and issuance，signature and receipt，processing，report issuance and report printing through the function of "specimen status inquiry" in real-time. (5) Nurses can inquire the information of their wards on reason，time and operator of returned specimens. Conclusions　The quality control of pre-analytic process into information systems not only facilitates understanding of the requirements of the relevant examination knowledge for clinicians and nurses in real-time，but also perfects training and communication systems of clinical laboratory to clinicians and nurses. It has been received highly recognized by medical laboratory technicians，clinicians and nurses.

田佳乐，戴燕，李冬，万海英. 将质量要求融入信息系统，以提高检验前质量控制能力[J]. 检验医学, 2012, 27(10): 844-848.

TIAN Jiale，DAI Yan，LI Dong，WAN Haiying. Integration of quality requirements into information systems to improve the quality control ability of pre-analytic process[J]. , 2012, 27(10): 844-848.